Local EMS was called to a nursing home in response to a resident who had pulled out her tracheostomy tube. Upon arrival, the patient was actively bleeding from the stoma, began coughing, and coughed out approximately 30 cc of clotted blood. EMS notified the local hospital that they would be bringing the patient to the local hospital before an anticipated transport to a larger acute care facility.
Upon arrival, the ambulance was reportedly met by nursing staff and the ED physician. The patient was briefly examined in the ambulance, and directed to transport directly to the next acute care hospital that was located approximately 15 minutes away. The ambulance had a paramedic, oxygen, and suction equipment on board. The patient was described as “fairly stable” with no respiratory distress observed.
Patient’s Best Interest?
The ED physician reported that the hospital had no capability to assess and stabilize the patient as their blood testing equipment was broken and that no surgical suite was open for placement of a tracheostomy tube. The ED physician asserted that it was in the patient’s best interest to send them on to the next facility. No exam, MSE, or care was provided, and no medical record was initiated.
Citations:
On the basis of the investigation, CMS cited the facility for:
1. Failure to log the patient (C2405)
2. Failure to provide a medical screening examination (C2406)
3. Failure to provide stabilizing care (C2407)
4. Failure to provide an appropriate transfer
Comments:
This scenario repeats itself frequently each year when a physician in an Emergency Department with limited resources, does a “look and go” contact with a patient who might be ultimately better served elsewhere. Good intentions, bad legal compliance.
Assuming that it truly is beyond this hospital’s capacity to care for this patient, EMTALA requires that the patient be brought in and receive a medical screening examination within the limited capabilities of the hospital. The physician is required to:
• Provide a medical screening examination within the available capabilities
• Provide what stabilizing care he/she can to reduce the risks during transport
• Document
• Certify the risks and benefits of transfer
• Obtain written patient consent to transfer, if feasible
• Get advanced acceptance from the destination hospital
• Send along copies of the medical record and document what was sent
• Put the patient back in the ambulance for transport with an appropriate crew and equipment
C2406-GA-2013-3-6
But are there times when a “look and go” is in the best medical interest of the patient?
“Look and go” is not an option under EMTALA. It gets cited every time they catch it. Without the advance acceptance, transfer forms, medical records, etc. the recipient hospital is obligated to report it.